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RA966  W85  Air  and  the  hospital 

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Columbia  (Bntoergitp 

College  of  $f)p*triang  ano  Buirgeons 
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AIR   AND  THE   HOSPITAL 


By  Prof.  S.  Homer  Woodbridge 

Of  the  Institute  of  Technology^  Boston 


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Thursday,  September  22 —  Afternoon  Session 

AIR  AND  THE  HOSPITAL 

By  Prof.  S.  Homer  Woodbridge 

Of  the  Institute  of  Technology,  Boston 


I. 

In  the  remedial  treatment  of  disease,  the  medical  profes- 
sion of  to-day  is  coming  to  recognize,  and  to  place  inc : 
ing  reliance  on,  the  primal  sources  of  vital  energy  as  their 
chief  and  indispensable-  allies.  The  effort  of  the  typical 
twentieth-century  practitioner  is  to  put  his  patient  into  the 
most  effective  relation  possible  with  those  sources  of  vital- 
ity. He  puts  his  patient  to  bed,  that  his  residuum  of  energy 
may  not  be  expended  in  external  work,  and  that  it  may  be 
conserved  and  directed  to  internal  repair.  He  prescribes  a 
diet  which  .-hall  contribute  the  most  to  the  in<  I  vital 

energy,  and  which  shall  tax  existing  energy  to  the  least  in  the 
processes  of  digestion,  assimilation,  and  nutrition.  He  de- 
.  prescribes,  and  sometimes  obtains  in  abundance  for 
bis  patient  that  which  is  tin-  co-equal  with  nourishing  food 
in  the  production  of  vital  energy,  pure  air.  He  reli( 
the  potent  helpfulness  of  a  healthful,  cheerful,  and  hopeful 
mind  presiding  over  the  tabernacle  it  inhabit-,  mysteriously 
affei  ting,  through  will,  imagination,  and  mood,  the  ni 
controlled  function-  of  the  introactive  and  interdependent  or- 
gan- of  the  complex  system  of  the  human  body.     I 

of  all,   in   remedial   importance  and   use,   i-  the  drug, 
whose  sole  and  subordinate  office  it  i-  to  remi 
to   nature'-   restorative   work,   and   to   stimulate   nerve-  and 
ins  to  normal  functions. 

The  pla<  e  of  pure  air,  in  -uch  restorative  treatment,  i- 
Ond   to  none.     All   recuperative  work   done  i-  done  by   vital 

3 


4  Air  and  the  Hospital. 

energy.  Vital  energy  is  a  part  and  phase  of  universal  en- 
ergy, transformed  from  energy,  previously  and  eternally  ex- 
isting in  some  form,  and  now,  for  the  moment,  vital  in  its 
phase. 

The  form  of  energy  from  which  man  draws  his  chief  sup- 
ply for  transformation  into  either  vital  or  dynamic  is  largely 
chemical.  Physical  life  is  a  process  of  energy  transforma- 
tion, principally  from  chemical  energy  —  residing  in  the  rela- 
tion of  the  carbon  of  foods  to  the  oxygen  of  the  air — in- 
to vital  energy.  The  essential  problem  of  vitality  is,  there- 
fore, that  of  the  adequate  appropriation  of  existing  energy, 
and  of  the  transformation  of  that  energy  into  vital  form. 

The  same  is  true  of  man's  industrial  life.  The  world  is  to- 
day producing  transformations  of  energy,  in  the  field  of  dynam- 
ics, at  a  prodigious,  almost  prodigal  rate.  On  the  one  side 
is  a  fixed,  and  therefore  limited,  supply  of  carbon  and  hydro- 
gen in  the  accessible  coal  stored  in  the  earth's  crust,  within 
man's  ready  reach.  On  the  other  side  is  an  unlimited  supply 
of  oxygen.  At  the  present  rate  of  use, —  three  million  tons 
of  coal  mined  per  day, —  man  is  drawing  heavily  on  that 
fixed  and  unrenewable  supply.  In  the  free  air  about  him  are 
one  thousand  million  millions  of  tons  of  oxygen,  which,  by 
a  wonderful  process  in  the  Creator's  great  laboratory,  is  re- 
stored by  vegetation  as  rapidly  as  it  is  used  in  the  energy- 
transformation  process  called  oxidation,  or  combustion. 

What  is  done  by  man  with  his  fuel  and  his  draft,  his  boil- 
ers and  his  engines  and  machinery,  in  changing  chemical 
energy  into  dynamic  energy  which  he  can  direct  and  apply 
to  the  doing  of  his  work,  and  the  development  of  his  indus- 
tries, is  also  done  in  the  body,  animal  and  human.  Food  is 
the  fuel;  ventilation  and  respiration  the  draft;  a  marvellous 
and  complex  organism  the  engine  and  mechanism.  In  its 
last  analysis,  the  body  is  an  energy  transformer  of  a  marvel- 
lously perfect  design,  worthy  of  its  creator.  The  energy,  wait- 
ing transformation,  is  His  also, —  the  carbon  and  hydrogen 
of  food  on  the  one  side  in  continuous  exhaustion,  and  peren- 
nial renewal,  so  long  as  sun  and  moon  shall  endure  and  seed- 
time and  harvest  shall  not  fail;  and  oxvgen  on  the  other  side 


5 

never  exhausted,  because  continuously  replenished  by  the 
very  process  which  furnishes  the  carbon  and  hydrogen  supply. 

Certainly,  to  the  thoughtful  student,  that  order  of  nature, 
and  the  place  and  procedure  of  man  within  it,  are  suggestive 
of  the  permanence  of  vital  energy,  and  of  the  transitor 
of  man's  materialistic  and  Babel-like  industry,  the  source  of 
one  being  perennially  renewed,  and  that  of  the-  other  being 
continually  exhausted  without  the  possibility  of  renewal;  one 
to  continue  and  increase,  the  other  to  run  its  temporary  pro- 
ductive course,  reach  its  limit,  and  then  decline,  except  as 
man  turns  again,  as  he  is  even  now  turning,  from  the  chem- 
ical energy  stored  in  fuel  and  oxygen  to  the  gravitation  en- 
ergy of  waterfalls  and  tides  for  turning  his  waterwheels,  and 
to  the  dynamic  energy  of  winds  for  driving  his  windmill-. 

This  is  man's  carbonigenous  age,  to  end  with  the  end  of 
bis  coal  finding  and  digging.  When  mines  are  exhausted,  then 
may  mind-  be  replenished  and  heart-  be  enriched  and  mel- 
lowed; and,  in  that  quiet  and  Less  materialistic  ome, 
like  the  lilies,  beings  of  heavenly  beauty  and  fragrance,  when 
the  toiling  world  stills  its  busy  bustle,  and  the  industrial  brain 
ceases  to  spin  it-  prodigies  i  if  energy  using  and  consuming  de- 

The  placing  of  man  in  his  normal  relation  to  the  infinite 
and  eternal  energy,  out  of  which  I  .  and  in  which  he 

"lives   and   move-   and    ha-   hi-   being,"    i-   the   fundamental 

truth  upon  which  the  study  of  our  subjeel  must  be  based  if 
our  thoughts  an-  to  be  rightly  conceived,  and  an-  to  issue  in 
correcl  conclusion  and  in  intelligent  action.  The  time  will 
come  when,  through  an  enlightened  science  in  reverential 

i o  ordination  with  divine Christology,  there  will  .ome  forth, 
as  there  has  nol  y<  I  ■  omi  ( Christian,  and 

a  Christianity  which  is  -rientilu  ;  when  the  "  I  am  that  I  am,'* 

the  infinite  and  eternal  energy,  shall  be  universally,  and  in 
everythii  that  which  is  "all  and  in  all;"  when 

all  work  directed  by  man,  in  the  driving  <>t'  his  enginery,  in 
the  propulsion  of  hi-  ships,  in  the  speeding  of  his  train 
the  night  of  his  i  annon  shot,  in  the  work  of  his  hand-,  in  all 
the  varied  voluntary  and  involuntan  activities  of  his  b 


6  Air  and  the  Hospital. 

shall  be  reverently  thought  of  as  done,  not  by  the  now  so- 
called  man-created  and  boasted  power  of  steam,  nor  by  the 
self- developed  power  of  the  body,  but  by  the  eternal  energy, 
name  it  as  we  will,  one  with  God  Himself,  put  within  man's 
reach  and  made  available  to  his  use  in  coal  and  in  air,  and 
in  other  stores  of  power  not  man-made  but  man  found  and 
used:  a  part  of  that  infinite  energy  which  "was,  and  is,  and 
ever  shall  be," —  the  "I  am"  without  which  nothing  is. 

The  function  of  the  physician,  and  of  the  hospital,  is  to 
bring  the  physical  life  of  man  into  the  largest,  surest,  most 
lasting,  and  most  active  relation  with  the  sources  of  his  vital 
energy;  to  put  and  to  keep  the  human  body,  that  composite 
system  of  energy  appropriation,  transformation,  and  utiliza- 
tion, into  a  complete  and  effective  relation  with  the  energy 
environment  which  is  both  the  origin  and  continuance  of  all 
his  being  and  activity. 

In  the  past,  the  physician's  function  has  been  pre-emi- 
nently restorative  in  character  rather  than  actively  construc- 
tive; it  has  been  healing  rather  than  preventing.  Inevitably, 
however,  the  logic  of  the  professional  work  of  the  physician 
has  produced  the  science  and  the  profession  of  hygiene,  and 
to-day  the  medical  profession  is  one  of  vitality  protection  and 
increase,  as  well  as  of  restoration.  It  therefore  stands  close 
to  Creatorship  and  to  healership,  and  at  the  very  pinnacle 
of  humaneness — for  the  reason  that  the  primary,  but  most 
unremunerative,  work  of  production  reduces  the  secondary 
and  most  remunerative  work  of  restoration.  Therefore,  in 
the  animus  which  inspires  it,  as  well  as  in  the  service  which 
characterizes  it,  the  profession,  as  it  becomes  less  one  of  med- 
icine and  more  one  of  hygiene,  is  justifying  the  high  Scrip- 
tural honor  bestowed  upon  it  in  likening  the  Great  Revealer 
of  Truth,  the  incomparable  Restorer  of  Humanity  to  truth- 
ful relations  with  its  infinite  environment,  —  in  likening  Christ 
to  the  human  physician. 

In  discussing  the  relation  of  air  to  vital  energy,  we  are 
therefore  plainly  dealing  with  one  of  the  most  important  of 
the  basal  truths  of  man's  relation  to,  and  dependence  on,  the 


Woodbridgc.  7 

sources  of  energy  which  are  placed  for  his  appropriation  and 
use  in  the  carbon  of  food  and  in  the  oxygen  of  the  air. 

If  the  study  of  that  subject  is  to  lead  us  to  truthful,  and 
therefore  right,  conclusions,  it  is  essential  that  no  relevant 
laws  or  facts  of  that  relation  be  slighted  or  minimized.  If 
food  abounds,  —  and  carbon  is  abundant  in  all  foods, —  and 
if  air  is  free  and  without  so  much  as  an  approachable  limit, 
and  oxygen  is  present  in  fixed  proportion  in  all  pure  air, 
why,  the  mind  careless  of  the  nicety  and  exactness  of  truth 
asks,  Why  all  this  discussion  and  agitation  and  legislation 
about  ventilation? 

The  fundamental  truth  or  law  on  which  the  demand  for 
ventilation  is  based  is  this:  though  nature's  resources  and 
operations  are  vast,  her  methods  and  requirement.-  are 
neither  coarse  nor  haphazard  nor  approximate,  but  exact ; 
precise  to  the  extreme.  The  great  worlds  composing  the  solar 
system  are  as  perfectly  adjusted  in  celestial  balance  as  are 
the  atoms  which  combine  to  make  up  any  substance  exactly 
proportioned  in  chemical  balance.  Remove  so  much  as  a 
planet's  satellite  from  the  solar  system,  and  the  whole  order 
of  movement  and  relation  of  the.  organic  bodies  is  altered, 
though  the  causal  change  is  but  one  one-hundred  millionth 
of  the  system's  bulk.  The  variation  of  one  thousandth  in 
the  carbon  entering  into  the  composition  of  the  hardest  of 
useful  steel  1  banges  it  into  a  comparatively  useless  metal.    A 

change  of  one  -i.x  hundredth   in  the  make  up  of  the  air.  by 

removing  it-  oxygen  and  increasing  it-  carbonic  gas,  de<  n 
the  normal   intensity  of  a  candle  flame  burning  in  that  air 
thirty  six  hundredths. 

The  exactness   without  variableness  tiled  natural 

law  i-  not  lessened  either  with  the  infiniteness  nor  with  the 
infinitesimalness  of  that  which  i-  subjei  t  to  that  law.   Neither 

vastnes  resource  in  anywise,  nor  in  any  d< 

exempt  the  user  from  that  law. 

The  air  a-  it   exists   in   the  open    i-   perfectly  and   exactly 

adapted  t«.  man'-  vitality  and  to  hi-  industry.    I  '   the 

proportion  of  oxygen,  and  hi-  vitality  exhau-t-  itself  in  its 


8  Air  and  the  Hospital. 

intensity.  Decrease  the  proportion  of  oxygen,  and  vitality 
droops,  languishing  in  the  dullness  of  its  unsupported  fires. 

In  his  industry,  man  may  at  will  quicken  or  lessen  his 
fires,  the  combustion  process  of  energy  transformation,  by 
increasing  or  by  decreasing  draft;  that  is,  by  increasing 
or  reducing  the  supply  of  oxygen  to  carbon.  Were  the  air 
all  oxygen,  the  coal  of  his  fire,  the  iron  of  his  furnace,  the 
flesh  and  bones  of  himself,  the  material  of  his  building,  would 
flash  into  a  form  of  energy  for  which  his  disembodied  spirit 
would  certainly  have  no  earthly  use.  The  air  as  it  is  is  meant 
for  human  vitality  and  for  human  industry  as  that  vitality  and 
industry  are  designed  to  be. 

The  air  as  it  is,  and  exactly  as  it  is,  in  the  open,  is  meant 
also  for  vegetation,  as  vegetation  by  nature  is  created  and 
sustained.  The  heating-pipes  which  warm  the  conservato- 
ries at  Mount  Vernon,  that  sacred  Mecca  on  the  Potomac, 
were  not  long  ago  covered  with  an  asphaltum  paint.  It  was 
in  early  summer,  and  the  paint  was  allowed  to  dry  and  to 
harden  until  the  middle  of  October,  when  pipes  were  heated 
for  expelling  all  deleterious  vapor  before  the  plants  should  be 
returned  to  shelter.  The  pipes,  when  heated,  yielded  scarcely 
a  trace  of  the  odor  commonly  following  the  first  heating  of 
newly  painted  pipes.  The  air  seemed  free  from  all  unnatu- 
ralness,  and  the  plants  were  placed  for  wintering,  and,  as  the 
result  proved,  for  dying.  Again  the  pipes  were  heated,  hot 
and  long,  and  the  conservatories  were  ventilated,  until  no 
trace  of  impurity  was  detectable  to  the  most  sensitive  olfac- 
tories; and  a  new  stock  of  plants  was  then  procured  and  in- 
stalled, only  to  yield  their  life  also  to  that  undetectable,  in- 
finitesimal something  which  neither  the  most  exquisite  sense 
of  smell  nor  the  most  sensitive  chemical  balance  could  de- 
tect. Again  the  pipes  were  heated,  and  the  enclosures  given 
a  prolonged  airing;  and  the  leaves  and  the  blossoms  of  other 
plants  whitened  at  their  edges,  and  the  whitened  fringe  spread 
toward  the  centre,  until  the  leaf  withered  and  the  flower  faded. 
Not  until  those  pipes  had  been  heated  in  the  hot  blaze  of  a 
blast  furnace-lamp,  and  the  last  remnant  of  that  volatile 
ethereal  something  had  been  driven  from  the  paint,  and  even 


Woodbridge. 

from  the  absorbing  iron,  was  the  life  of  plants  made  safe  in 
those  conservatories. 

Such  is  the  testimony  given  by  the  (lame  of  the  candle  and 
the  flower  of  the  plant  to  the  law  of  exactitude  in  the  vital 
processes  of  nature.    If  the  senseless  flower  and  the  insensi- 
ble  flame  are  subject  and  keenly  susceptible  to  that  law,  how 
much  more  the  human  organism,  with  its  complex  and  ex 
quisite  sensoria,  with  its  imagination  and  thought,  and  their 
reflex  influence  on  vitality  and  the  vital  processes!    Known 
to  you,  better  than  to  any  other  class  of  students  and  obsen 
ers,  are  the  benefits  which  changes  in  the  air,  from  vall< 
mountain,  and  from  mountain  to  seashore,  work  for  patient- 
—  though  neither  chemist  nor  physicist  might  be  able  to 
measure  the  atmospheric  variation  producing  the  change. 

Such  is  the  convincing,  if  not  the  invincible  setting  forth 
of  basal  truths  which  lead  up  to  the  conclusion  that,  if  vital- 
ity is  to  be  sustained  at  its  best,  the  energy  containing  air 
must  be  maintained  at  its  best. 

Abundance,  arid  therefore  purity,  of  air  is  of  more  impoi 
tance  to  the  boiler  furnace  than  is  quality  of  fuel.    With  a 
poor  draft  the  mosl  successful  and  faithful  fireman  can  do 

little,  even  with  the  best  of  COal.  With  a  good  draft  he 
Can  make  and  keep  a  hot  lire  with  poor  coal.  So  also  for  vital 
tires  purity  of  air  is  more  essential  than   is  purity  of   food. 

The  on»-  is  created  and  provided  without  human  instrumen 
till  it  \ ;  and  environed  in  it  man  continuously  lives,  and  of  it 
he  as  continuously  breathes. 
Food,  made  or  provided  through  human  instrumentality, 

IS  partaken  of  only  at  inlen  als.    I  lowevei  viewed,  as  to  origin, 

continuant  e  of  use,  .1-  to  important  e  of  purity,  air  rank- 
above  food  in  vital  important  e. 

Ki>ks  attending  dangers  an-  proportional  to  the  oatun 
exposure  to  them.   Kisks  m:,y  be  measured  first  by  the  phya 
ical  status,  or  susceptibility,  of  tin-  one  exposed;  and  second 
by  tlir  character  of  the  menace;  and  third  by  the  time  or 

duration  of  exposure  t<>  the  a<  lion  of  the  Qai 

A  two  minutes'  dash  lU  pOSS  a  battle  field  i-  hazardous,  but 
a   si\   hours'  stand  on  the  firing  line   is   more  s(1  l>y   |,n 


i  o  Air  and  the  Hospital. 

also  in  reference  to  susceptibility  to  dangers  lurking  in  im- 
pure air, —  impure  by  impoverishment,  by  moribific  con- 
tents, gases,  vapors,  microbic  or  other  dusts.  Some  breath- 
ers have  such  a  reserve  of  robust  vitality  that  the  effects  of 
exposure  are  so  slowly  cumulative  as  to  make  exposure  of 
short  duration  attended  with  small  risk.  Others  with  depleted 
vitality  are  quickly  and  obviously  affected  by  pathogenic  con- 
ditions to  which  the  stalwart  are  immune. 

Ventilating  work,  when  intelligently  planned  and  faith- 
fully performed,  takes  due  cognizance  of  the  foregoing  fun- 
damental truths  and  principles;  and  of  the  laws  of  nature  on 
which  that  work  must  be  based  if  it  is  to  be  correct  in  appli- 
cation and  effective  in  results.  It  regards  the  hospital  as  the 
retreat  of  vitality  depleted  through  the  shock  of  accident  or 
the  waste  of  disease,  and  therefore  the  place  of  all  others 
where  the  physical  condition  of  the  subject  demands  the  full- 
est purity  of  vitalizing  air.  Furthermore,  the  time  of  dura- 
tion of  exposure  to  conditions  maintained  in  the  hospital  is 
long,  compared  with  that  of  exposure  to  the  air  of  theatres, 
lecture  or  music  halls,  or  churches,  public  conveyances,  land 
or  sea.  Temporarily,  for  longer  or  shorter  periods,  the  hos- 
pital is  as  continuously  occupied  as  is  the  dwelling-house, 
and  more  so  than  the  office  and  the  school  building.  The 
two  considerations,  therefore,  of  the  state  of  susceptibility  of 
body,  and  also  of  the  time  of  duration  of  exposure,  conspire 
in  the  demand  for  a  more  free  ventilation  of  hospitals  than 
of  any  other  class  of  buildings  for  human  occupation. 

Vital  depletion,  duration  of  exposure,  and  the  specific 
dangers  to  which  patients  are  exposed  vary  within  wide  lim- 
its within  the  hospital  itself.  Some  effluvia  which  permeate 
the  air  of  hospital  wards  are  emanations  from  those  afflicted 
with  contagious  diseases.  In  such  cases,  ventilation  should 
perform  the  triple  office  of  invigorating  the  patient,  of  diluting 
the  germ  dust,  and  also  of  protecting  those  uninoculated  by 
the  disease.  Such  work  requires  the  maximum  per  capita  of 
air-supply  called  for  in  good  ventilation. 

In  surgical  wards  are  those  reduced  by  the  shock  of  oper- 
ation, augmented,  it  may  be,  by  that  of  accident.    In  the 


Wo  <dbt  1 1 

air  may  float  pus  pustules,  the  germs  of  gangrene,  or  the 
sloughed  scales  of  healing  wound.-,.  In  these  instances  is  en- 
feebled vitality  on  the  one  hand,  but  less  danger  in  the  qual- 
ity of  the  contents  of  the  air  on  the  other.  Floating  dus 
less  microbic,  or  the  microbic  form  is  less  dangerous  in  char- 
acter, than  in  a  contagious  ward.  The  air-supply  may  there- 
fore be  reasonably  reduced  from  the  quantity  appropriate 
to  the  contagious  ward. 

The  physical  situation  in  the  general,  or  medical,  wards  is 
marked  by  vitality  depression,  and  the  atmospheric  condition 
by  an  absence  of  moribific  quality.  A  lower  per  capita  air- 
supply  is  therefore  admissible  than  for  either  the  contagious 
or  surgical  wards. 

It  would  be,  indeed,  well  could  all  wards  of  all  hospitals  be 
so  supplied  and  flushed  with  air  from  the  open  country  that 
a  residuum  of  its  ozone  might  be  found  even  in  the  spent  air 
passing  away  from  them.  If  the  air  of  city  Streets,  devoid  of 
ozone,  must  be  drifted  through  the  wards,  a  judicious  addi- 
tion of  artilicial  ozone  would  probably  be  advantageous,  and 
especially  so  for  contagion-  and  surgical  ward-,  and  for  oper- 
ating-rooms. 

What  shall,  or  perhaps  we  may  more  safely  ask,  what 
should  be  'In  gauge  of  air-supply  t<>  these  several  parts  of 
the  hospital  ? 

No  air  can  be  too  pure  for  the  need  and  use  of  the  most 
virile  vitality  —  certainly  not  for  impaired  vitality.  It  atmos- 
pheric  impurity  is  to  be  maintained  at  a  minimum,  then  at- 
mospheric quantity  must  be  maintained  at  a  maximum.  Why, 
then,  limit  quantity,  when  air  i-  free,  and  environ-  US 

greal  ocean,  world  wide  in  expanse,  and  whose  fathom 

mil. 

Be  >me  things  other  than  atmospheric  taint 

equally  insufferable  and  hazardous.    Chief  among  thea 
draft-,     drafts  on  the  purse  and  draft-  on  the  person.    En- 
durable drafts  on  the  purse  arc  directly  proportional  to  the 

Volume  and  valu.-  of  the  individual  hank  annum.     1  I 

the  person  an-  inversely  proportional  to  t!  \pita  vol- 

ume, or  space,  within  the  room  ventilated. 


i  2  Air  and  the  Hospital. 

The  larger  the  bank-account,  and  the  more  spacious  the 
rooms,  the  greater  the  per  capita  air-supply  may  safely  and 
profitably  be.  The  United  States  Senators,  with  the  country's 
mines  and  the  country's  mints  behind  them,  and  housed  in 
a  spacious  chamber,  are  given  a  minimum  air- supply  of  150 
cubic  feet  (40  bbls.)  per  minute.  The  official  inspectors  for 
the  State  of  Massachusetts  fix  the  minimum  for  scholars  in 
the  public  schools  at  30  cubic  feet  per  minute  —  for  reasons 
of  bank  drafts  and  air  drafts. 

If  gain  to  health  were  proportional  to  air-supply,  a  use  of 
the  largest  possible  supply  might  properly  be  urged,  as  also 
an  unlimited  spaciousness  of  rooms  which  would  permit  of 
the  use  of  such  air  quantities  without  drafts. 

Such,  however,  is  far  from  the  fact.  The  resulting  incre- 
ment of  vitality  gain  falls  off  with  each  increment  of  air-sup- 
ply. The  ratio  of  that  gain  is  almost  inversely  as  the  ratio  of 
the  air-supply.  On  the  first  100  cubic  feet  of  air  per  capita 
per  hour  hangs  life  or  death.  On  the  twentieth  100  cubic 
feet  per  hour  hangs  a  certain  degree  of  vivacity,  or  its  ab- 
sence. On  the  Senatorial  ninetieth  100  cubic  feet  of  air-sup- 
ply per  hour  hangs  not  so  much  as  a  single  Senator's  vote 
on  a  private  pension  bill! 

Somewhere,  the  minimum  and  the  maximum  limits  for 
air-supply  must  be  placed.  The  hospital  is  not  a  fitting  sub- 
ject to  invite  a  discussion  of  such  minimums.  Of  all  places, 
the  hospital  is  the  place  for  maximums  in  all  that  can  in- 
crease strength  and  restore  health,  and,  therefore,  most  of 
all,  in  air.  Everywhere,  but  most  of  all  in  the  hospital,  the 
rule  of  ventilation  should  be,  "The  maximum  admissible, 
rather  than  the  minimum  tolerable." 

The  cost  of  warming  air  for  ventilating  purposes,  where 
coal  can  be  had  at  $5  per  ton,  and  where  the  outside  climate 
during  the  closed  season  averages  350  F.  below  the  indoor 
temperature,  and  where  fuel  is  not  badly  wasted  in  fires,  is 
twenty  cents  for  each  1,000,000  cubic  feet  of  air  used,  equiv- 
alent to  a  per  capita  supply  of  4,000  cubic  feet  an  hour  for 
ten  days  of  twenty-four  hours  each,  or,  roughly,  two  cents  a 
day  for  100,000  cubic  feet  of  pure  air! 


Woodbrui^e.  1 3 

If  it  be  possible,  by  such  a  pittance  in  expenditure,  to  pro- 
vide in  any  other  way  the  essentials  for  energizing  human 
vitality,  whether  it  be  in  restoring  the  sick  to  health  or  in 
qualifying  the  well  for  the  most  virile  life  and  productive  work, 
let  some  one,  yet  unknown,  if  not  unborn,  bless  his  race  by  dis- 
closing that  yet  undiscovered  boon ! 

What  supply,  then,  shall  be  given  to  those  sick  with  infec- 
tious disease,  to  restore  vitality,  to  dilute  and  remove  the 
moribific  contents  of  air,  to  protect  those  uninoculated  with 
the  disease?  A  maximum  of  8,000  cubic  feet  per  hour  for 
each  bed  is  surely  a  rational  demand.  And  what  for  the  sur- 
gical ward,  where  life  often  hangs  by  a  thread,  and  the  vital 
flame  burns  low,  and  microbic  dusts  are  liable,  and  should 
be  absent  ?  Surely,  a  per  capita  supply  of  6,000  cubic  feet  an 
hour  is  a  moderate  maximum.  For  the  medical  ward,  and 
for  average  cases,  that  limit  may  be  fixed  at  4,000  cubi( 
an  hour  for  each  bed. 

II. 

Passing  from  general  principles  to  -"me  of  the  more 
cific  methods  to  be  followed  in  tin-  ventilation  of  hospitals, 
tin-  first  suggestion  relate-  to  the  importance  of  so  ventilating 
some  parts  <>f  the  hospital  as  to  protect  others  than  the  patients 
occupying  them ;  or,  in  other  words,  the  use  "t  such  a  method 
of  ventilation  in  particular  cases  a-  shall  prevent  the  escape 
of  air  from  the  affected  rooms  to  other  rooms,  <>r  to  1  orridors 
connecting  with  such  rooms.   Such  ventilation,  to  be  effective, 
must  effectivel]  isolate  that  room,  atmospherically,  from  its 
surrounding-.    To  1 mplish  that  result,  its  provided  dis- 
charge Mutilation  must  be  in  1  of  it-  provided  supply 
ventilation.    Rooms  requiring  such  so-calli 
tilation *'  are  contagious  wards,  privati  ml.  sanil 
operating,    mortuary,    etherizing,    and    bath    room-,    V: 

quarters,  lockers,  and  lavatory  rooms.  Themaji  iper 

ating  to  ventilate  those  room-  should  be  on  the  side  of  <iis 
charge  rather  than  on  that  of  supply.    The  air  "t 

and  adjacenl    room-  would  then   tend   to  move  toward  and 
into  the  vacuum  ventilated  room-,  rather  than  from 


14  Air  and  the  Hospital. 

rooms  into  surrounding  quarters.  The  means  required  to 
accomplish  those  results  are  a  proper  size  of  exhaust  or  dis- 
charge flues,  and  sufficient  strength  and  sureness  of  draft  in 
them.  Such  means  are  easily  obtainable  by  a  proper  area  of 
flue,  height  of  flue,  and  heat  in  flue,  or  by  a  suitable  fan- 
power  connected  with  the  exhaust  part  of  the  ventilating  sys- 
tem. 

The  second  suggestion  is  that  other  sections  of  the  hos- 
pital should  have  a  greater  strength  of  ventilating  work  on 
the  supply  rather  than  on  the  discharge  side.  Such  ventila- 
tion should  be  furnished  to  all  wards,  private  or  general, — 
for  other  cases  than  infectious, —  and  for  all  living,  admin- 
istrative, and  work  quarters,  other  than  those  named  as  more 
properly  ventilated  by  a  predominance  in  vacuum  action. 

By  maintaining  a  condition  of  lower  atmospheric  pressure 
in  those  parts  of  the  hospital  which  should  be  atmospherically 
isolated,  and  by  maintaining  at  the  same  time  a  higher  pres- 
sure in  those  parts  which  should  be  protected,  the  trend  of 
air  movement  is  made  to  set  from  the  quarters  in  which  the 
air  should  be  maintained  at  its  purest,  toward  and  into  those 
in  which,  from  one  cause  and  another,  the  contained  air  must 
of  necessity,  and  may  without  harm,  be  more  or  less  contam- 
inated by  impurities  which  vary  from  the  dangerous  to  the 
offensive,  and  to  the  relatively  innocent. 

The  third  suggestion  is  that  what  should  be  done  in  the 
manner  described  for  the  hospital  as  a  whole  should  also  be 
done  for  special  quarters.  There  is,  for  instance,  no  ade- 
quate justification  for  allowing  the  offensive  odors  attending 
excremental  discharges  to  escape  from  water-closet  seats, 
and  to  diffuse  through  rooms  for  dilution  in  air  previous  to 
its  breathing;  nor  for  the  heat,  steam,  smoke,  and  fumes 
from  a  range  to  fill  the  entire  kitchen  before  any  attempt  is 
made  to  remove  them.  Here,  again,  the  drift  of  air  move- 
ment should  be  toward  the  vitiated  locality,  so  strongly, 
surely,  and  continuously  that  the  offenses  shall  be  confined  to 
the  place  of  their  origin,  and  removed  without  so  much  as  a 
chance  of  mixing  with  air  the  purity  of  which  should  be  main- 
tained for  breathing. 


Woodbrt  1 5 

The  general  law  governing  these  matter-,  and  applicable 
to  all  ventilating  work,  and  eloigned  to  insure  effectiveness 
and  economy  in  that  work,  is  that  of  limitation  and  removal 
by  saturation,  as  against  diffusion  and  removal  by  dilution. 
Ten  cubic  feet  of  air  a  minute  moving  toward,  into,  through, 
and  out  from  a  water-closet  seat  will  more  effectively  protect 
the  room  against  excremental  offenses  than  ten  or  twenty 
times  that  quantity  of  air  passed  through  the  room  itself  — 
just  as  the  throat  of  a  fireplace  moving  one  hundred  feet  of 
air  and  -moke  a  minute  from  the  tire  burning  on  the  hearth 
will  keep  the  room  free  from  tear-making  smoke  as  one  thou- 
sand cubic  feet  per  minute  would  not,  and  could  not,  if  the 
same  lire  burned  on  an  open  hearth,  as  in  the  olden  time,  in 
the  centre  of  the  room. 

These  matter-  of  excremental  and  renal  offenses  are  Dot 
selected  and  emphasized  a-  of  special  hygienic  importance. 
Too  much  is  frequently  made  of  them  as  specific  sources  of 
danger.  Except  for  reflex  action  they  are  relatively  innocent 
hygienically,  especially  in  the  state  of  tir.-t  discharge,  and  so 
long  afterward-  ;i-  they  may  be  prevented  from  dessication 

and    forming   part   of   breathed   dust.      Reflex   actions,    how 

.  are  not  unimportant.    Rather,  they  play  such  an  ait 
ive  pan   in  the  complex,  sensitive,  physiological  system  of 
our  body  thai  they  are  often  disturbing,  and  may  be  dai 
ou-.  in  their  effects. 

\  naval  radet  from  Annapoli-,  who  had  failed  to  find,  or 
fit,  his  sea  legs,  and  had  suffered  much  aboard  training  ship 

at  sea,  was  unexpectedly  confronted  one  day  in  Washington 

by  a  naval  officer  in  full  uniform,  who  entered  the  sti 

tar  in  which  the  i adei  chanced  to  be  riding.    The  i 

that  sea  uniform  on  the  cadet's  stomach  is  reported  to  have 

resulted  in  the  spontaneous  eje<  tion  of  il 

the  cadei  could  reach  the  platform.    Like  ejectivi 

attending  the  odor  emanating  from  offensive  evacuat 

have  been  known  to  temporarily  disable  an  amateur  ni 

Cadet  and  nurse  wen-  the  sul  ■■..  nervou 

lion,  one  originating  in  the  optical,  and  the  other  in  the  n 

organ-. 


1 6  Air  and  the  Hospital. 

The  susceptibility  of  the  complex,  sensitive,  and  exquisitely 
interdependent  and  introactive  system  of  the  human  body 
makes  harmful,  sometimes  even  deadly,  things  which  in 
themselves  are  wholly  innocent  of  poison  or  moribific  tend- 
encies in  their  direct  influence  on  organs  indirectly  affected. 
Some  things  which  have  no  existence  at  all,  except  in  the  im- 
agination, sometimes  effect  serious  reflex  results.  Very  re- 
cently a  sagacious  surgeon  of  Philadelphia  performed  what 
was  perhaps  a  life-saving  operation,  in  removing  a  wholly 
imaginary  obstacle  from  the  oesophagus  of  a  long-suffering 
patient  who  for  six  months  had  scarcely  been  able  to  worry 
into  his  stomach  enough  liquid  food  to  sustain  his  life.  The 
imagination,  rather  than  the  obstacle,  was  removed,  and  the 
way  was  immediately  cleared  for  gratifying  a  famished  stom- 
ach with  a  hearty  meal  of  solid  food. 

The  matter  of  reflex  action,  through  imagination  and  whim 
and  sensation,  is  one  of  large  importance  in  the  domain  of 
ventilation.  In  no  territory,  except,  possibly,  in  the  more 
occult  and  confused  realms  of  medicine  and  theology,  is  there 
such  a  wide  and  productive  field  for  the  play  of  the  imagina- 
tion, and  for  the  rank  growth  of  its  offspring,  as  in  this  field 
of  ventilation.  Imagination,  sensation,  agreeableness,  must 
be  consulted,  reckoned  with,  pacified  and  gratified,  if  suc- 
cess is  to  be  complete,  if  the  physiological  results  for  which 
ventilation  is  furnished  are  to  be  realized.  All  this  is  a  field 
in  which  the  bearing  of  psychology  on  physiology  is  so  fully 
and  strongly  exemplified  as  to  suggest  its  value  as  one  of 
profitable  research  for  students  in  both  departments. 

Large  and  intelligent  audiences  have  contentedly  breathed 
the  overladen  air  of  unventilated  audience-rooms  when  only 
the  semblance  of  ventilating-registers  have  been  conspic- 
uously painted  upon  the  walls,  and  have  hysterically  pro- 
tested against  the  "horrible  air"  of  perfectly  ventilated 
rooms  when  the  means  for  ventilation,  not  conspicuously 
evident,  were  unnoticed. 

John  and  Jane  are  two  very  real  New  England  characters. 
The  business  engagements  of  John  make  necessary  occa- 
sional travelling  by  night.    Quite  recently  his  bosom  compan- 


Woodbridge.  i- 

ion,  Jane,  accompanied  him  on  one  of  these  sleeping-car 
trips.  John  dreads  the  berth  of  the  sleeping-car  almost  as 
much  as  the  door  of  a  tomb.  He  generally  contracts  a  cold, 
which  usually  develops  into  acute,  and  sometimes  alarming, 
symptoms.  On  the  occasion  referred  to,  John  occupied  the 
upper,  and  Jane  the  lower,  berth.  In  his  sleeplessness  he 
heard  from  below  murmurs  of  discontent,  and  on  inquiring 
into  the  cause  was  told  that  the  air  was  so  intolerably  close 
as  to  make  sleep  impossible,  and  was  urgently  asked  that  the 
window  be  opened  for  the  admission  of  fresh  air.  To  this 
request  John  strongly  demurred,  knowing  the  distressful 
sequence  so  often  experienced  in  his  own  case.  Jane  sub- 
sided complacently.  Later  in  the  night  the  sounds  of  discom- 
fort from  below  led  John  to  again  inquire  as  to  its  cause. 
This  time  the  expression  of  discomfort  was  extreme,  and  the 
in>istence  upon  relief  imperative.  Reluctantly,  John  lowered 
himself  to  the  floor,  reached  over  the  berth  to  the  window  at 
its  foot,  and  with  some  effort  and,  let  it  be  hoped,  affection- 
ate warning,  and  with  deliberate  and  delicately  solicitous  in- 
tent, raised  the  inner  sa>h  of  the  double  window,  and  climbed 
back  to  his  berth.  In  a  few  minutes  all  was  quiet  below,  and 
sleep  for  the  remainder  of  the  night  was  as  sound  and  sweet 
as  that  of  tin-  just.  The  conditions  remained  unchanged, 
except  that  the  inner  sash  was  lifted,  while'  tin-  outer  sash  re- 
mained tightly  closed;  but  imagination  was  gratified,  and 
sleep  was  induced. 

The  purpose  "f  ventilation  is  definite  and  simple.    What 
ever  legitimately  contributes  to  the  attainment  «>f  that  pur- 
is  a   proper,  and  may  be  a   most    important,  auxiliary 
means  to  the  end.    The  rellex  influence  of  mental  mood  and 
action    is    potent   and    keen  and    must   not   be    discounted  01 

minimized.  The  nose  must  not  be  offended,  although  there- 
be  nothing  noxious,  per  se,  in  the  offense.  'I'lu-  eyes  must 
appeal  to  satisfying  rather  than  to  disturbing  sensibilities. 
Therefore,  water-closet  and  urinal  odors  should  be  confined 

I  ,nl\  ,i  jpo     ible  to  their  appropriate  plat  <  3,  and  rem 
without  escape  and  without   mixture  with  air  for  Invar 

notwithstanding  the  obvious  and  universal  fact  that  the  pel 


1 8  Air  and  the  Hospital. 

vie  offenders  are  individually  and  continuously  within  a  rel- 
atively few  inches  of  the  sensitive  olfactories,  and  the  draft 
of  air  moved  through  the  chimney-like  space  between  the  skin 
and  the  clothing  is  from  pelvic  to  nasal  regions.  It  is  not  al- 
ways those  most  cleanly  in  person  who  are  most  vociferous 
in  their  outcry  against  the  imaginary  evils  of  the  offensive  air 
of  sanitary  quarters. 

Applied  to  ventilation  work  in  general,  a  rule  which  may 
be  safely  adopted  is  that  the  evidence  of  ventilation  should 
accompany  its  action.  Such  evidence  should  be  everywhere 
reasonably  conspicuous.  The  inflowing  and  outflowing  air- 
way, so  far  from  being  concealed,  should  be  attractively  vis- 
ible. The  air-flow  through  such  ways  may  be  made  help- 
fully evident  by  fluttering  ribbons.  The  floating  and  wav- 
ing of  belittled  "Old  Glories"  in  the  stream  of  air  entering 
rooms  from  supply  registers  have  been  used  to  contribute 
their  optical  effects  to  securing  the  hygienic  ends  sought. 

First  of  all,  ventilate,  appropriately,  efficiently,  thoroughly, 
and  then  impress  upon  the  subject,  by  all  needed  and  legit- 
imate means,  the  fact  of  that  ventilation. 

III. 

How  shall  ventilation  be  done?  What  method  is  best? 
What  means  are  most  appropriate  and  desirable  ?  What  sys- 
tem is  ideal? 

Such  large  questions  cannot  be  treated  with  practical  profit 
in  a  discussion  limited  to  minutes.  Ways,  and  means,  and 
systems  are  many,  and  circumstances  have  as  much  to  do 
with  determining  specific  fitness  as  symptoms,  and  schools, 
and  the  professional  or  the  patient  factor  have  to  do  with  de- 
termining prescriptions. 

As  in  the  practice  of  medicine  the  physical  factor  of  the 
patient  must  be  consulted  and  regarded,  so  in  the  engineer- 
ing practice  of  ventilation  it  is  found  advisable,  and  some- 
times highly  important,  to  pay  due  regard  to  the  physiolog- 
ical idiosyncrasies  of  the  client. 

There  is,  however,  one  method  of  ventilation  which,  when 


Woodbridge.  i  g 

admissible,  is  incomparably  the  best  in  simplicity,  efficiency, 
and  economy.  The  method  is  the  wind,  and  the  means  the 
windows.  In  the  quantity  of  air  moved,  and  in  the  effective- 
ness of  ventilating-work,  human  ingenuity  and  enginery  can- 
not approach  the  results  obtained  by  perflation. 

Artificial  ventilation  can,  at  the  best,  be  only  a  substitute 
for  such  natural  ventilation.  Artificial  ventilation  is  necessa- 
rily no  more,  nor  no  better,  than  a  substitute  for  that  which 
is  natural  and  perfect.  No  forcing  of  air  through  provided 
ways  and  ramifying  flues  by  spanking  it  with  paddle  fan 
blades,  or  putting  it  under  the  screws  of  the  propeller  fan, 
or  torturing  it  with  the  hot  irons  of  steam  heaters  can  make 
it  do  all  it  stands  waiting  to  do  if  given  the  adequate  oppor- 
tunity for  doing  its  own  work  in  its  own  way. 

The  insuperable  obstacle  to  the  universal  and  continuous 
use  of  the  natural  or  open  window  and  door  method  is  in  tin- 
nature  of  out-of-door  climate  during  the  portion  of  the  year 
when  artificial  ventilation  must  be  resorted  to.  Only  in  tin- 
equatorial  zone  and  adjacent  territory  is  free  and  abundant 
ventilation  by  nature's  methods  possible  during  the  entire 
year.  In  the  temperate  and  colder  zones  artificial  warmth 
must  be  maintained  in  buildings  for  occupancy  during  fully 
one  half  or  more  of  the  year.  Outside  cold  must  be  excluded; 
and  as  air  in  its  natural  condition  cannot  be  admitted  with- 
out also  admitting  cold,  a  limitation  must  be  plat  ed  upon  the 
air  supply,  and  therefore  upon  ventilation.  That  fact,  how 
ever,  docs  not  wholly  preclude  a  use  of  the  natural  method, 
even  in  the  i  old  of  the  northern  winter  season.  What  cannot 
be  i  ontinuouslyused  with  safety  maybe  temporarily  used  with 

profit.     Wards,  living  rooms,  dining  rooms,  almost  all  <|iiar 

ters  of  the  hospital,  may  be  advantageously  flushed  with  an 
inflow,  through  flow,  and  outflow  of  the  purest,  most  invig 
orating,  and  hast  "doctored  and  manipulated"  air  obtain- 
able. For  the  purpose  of  making  such  a  method  of  ventila- 
tion usable  and  useful  to  the  maximum,  architects  should 
provide  U<v  it  bv  furnishing  transom  windows,  which  when 
opened  will  throw  the  entering  air  upward  and  reduce  floor 
draft-  to  a   minimum.     Such   transoms  should   be  furnished 


20  Air  and  the  Hospital. 

with  cheeks  for  preventing  a  lateral  inflow  of  air,  and  for  in- 
suring an  upward  flow  only.  The  air -currents  will  then  ex- 
pend their  draft  force  near  the  ceiling,  the  entering  cool  air 
will  mingle  with  the  warm  air  of  the  upper  room  before  de- 
scending to  the  floor;  drafts  will  be  reduced,  and  inflowing 
air  will  be  tempered  before  the  breather  is  reached.  The 
benefits  of  such  a  method  of  ventilation  are  important  and 
large,  provided  the  inflow  of  air  is  free,  and  that  harmful 
drafts  and  chilling  effects  are  eliminated. 

The  occasions  calling  for  the  use  of  such  window  ventila- 
tion are  any  which  excessively  and  abnormally  vitiate  the 
air  of  the  wards  or  other  enclosures  of  the  hospital.  It  may 
follow  the  round  of  the  visiting  physician,  the  opening  of 
beds,  or  any  other  occasion  which  actively  and  excessively 
vitiates  the  air  of  the  ward. 

Continuous  ventilation  of  the  same  type,  but  much  more 
limited  in  degree,  may  be  had  by  filling  the  opened  "sash 
spaces  of  windows  with  a  cloth  of  open  mesh,  such  as  the 
finer  grades  of  cheese-cloth.  The  cloth  may  be  stretched  on 
frames  similar  to,  or  identical  with,  those  of  the  fly-screen 
frames.  For  mild  cold  weather  a  single  thickness  of  such 
cloth  may  answer,  and  for  colder  weather  one  thickness  of 
the  cloth  on  each  side  of  the  frames.  This  method  requires 
a  surface  of  cloth  corresponding  to  the  rate  of  air-flow,  or  of 
its  diffusion,  through  the  cloth  between  the  inside  and  out- 
side air.  A  square  yard  to  each  breather  is  a  fair  amount  of 
surface,  if  the  outside  air  is  quiet,  and  if  the  conditions  within 
are  not  such  as  to  make  the  inward  movement  of  air  too  rapid 
for  its  proper  warming.  The  action  in  the  case  of  the  double 
stretch  of  cloth  is  partially  one  of  warming,  since  the  in- 
moving  air,  which  is  cold,  meets  and  diffuses  with  the  out- 
going air,  which  is  warm,  the  latter  imparting  a  considerable 
part  of  its  heat  to  the  cold  and  inward  moving  air. 

The  method  has  been  found  applicable  to  and  advanta- 
geous in  the  sick-rooms  of  private  residences;  and  it  may  as 
easily  and  profitably  be  applied  to  the  wards  and  other  rooms 
of  hospitals  which  are  without  incorporated  systems  of  ven- 
tilation. 


Woodbridgc.  2 1 

This  method,  and  more  especially  that  of  perflation,  may 
be  made  a  valuable  adjunct  to  any  system  of  artificial  venti- 
lation. Such  ventilation  is  by  a  method  rather  than  by  a  sys- 
tem. A  system  involves  and  includes  more  than  is  necessary 
for  a  method.  A  broken  pane  of  glass  affords  ventilation, 
not  by  a  system  but  by  a  method;  so  also  an  open  window  or 
door;  so  also  a  fireplace.  A  system  implies  an  association  of 
co-related  parts  with  reference  to  a  functionary  end.  A 
tern  of  ventilation,  therefore,  means  a  combination  of  de- 
vices for  air  inflow  to  buildings,  for  its  distribution  through 
buildings,  for  its  diffusion  through  rooms,  and  for  its  re- 
moval from  rooms.  As  to  how  best  to  plan,  install,  and 
operate  a  system  of  ventilation,  no  more  than  a  few  mo- 
ments can  here  be  given. 

How  shall  air  best  be  used  when  once  within  the  wall-  of 
a  hospital?  Certainly  it  must  be  prevented  from  coursing 
through  rooms  without  effecting  the  intended  ventilating 
work.  Instead  of  being  like  the  gulf  stream,  running  it- 
course  of  4,000  miles  without  mingling  with  the  great  ma-> 
of  water  over  which  it  flows,  the  air  current  musl  move,  and 
equally  move,  every  part  of  the  air  of  tin-  room  which  it  is 
furnished    to   ventilate.      How   shall   this   diffusion   of   move 

ment  be  effected?    It  may  be  done  in  variou>  ways — some 

elaborate  to  a  degree  wholly  unnecessary;  some  simple,  yet 
effective.  In  the  distribution  of  air  through  rooms  nature 
comes  to  the  aid  of  artifice,  and,  by  an  engine  like  action  be 

tween  heat  and  cold,  the  chilliness  of  wall  LSS  throw 

down,  or  pro  ipitate,  air  all  about  the  perimeter  0!  rooms;  and 

the  rays  <>\  solar  heat,  warming  iloor-,  and  other  heal 
within  the  room  sel  columns  of  air  in  upward  motion  in  1 
centres.  The  total  effeel  is,  then  ton-,  to  move  and  mix  the 

whole  mass  of  air  inclosed  within  the  wall-.    To  this  pn 
man   may  effectively  contribute   by   his  method   of  entering. 

diffusing,  and  discharging  air:  or  he  may  wholly  disn 

the   natural   movements  of  air  within  such  room-,  and 

1st  nature  in  tin-  process  he  proposes,    [f  h< 

skilled,    he   will    in   each   case   note   nature'  tion,    and 

make  his  own  work  co  operative  with  natui 


22  Air  and  the  Hospital. 

Though  he  may  give  little  heed  to  nature's  part  in  the  proc- 
ess, the  correct  designer  of  a  method  for  air-diffusion  must 
yet  appreciate  the  necessity  of  evenly  distributing  and  dif- 
fusing the  air  employed.  If  he  is  versed  in  methods,  or  re- 
sourceful in  devising  them,  he  will  be  able  to  suggest  a  va- 
riety of  courses  to  be  followed,  according  to  the  circum- 
stances which  may  require  or  favor  them.  Distribution  may 
be  effected  by  either  of  the  following  general  methods:  first, 
through  a  multitude  of  scattered  and  well-placed  points  for 
inflow  and  for  outflow;  or  by  a  single  point  for  inflow  and 
many  distributed  points  for  outflow;  or  by  a  single  point  for 
outflow  and  many  and  distributed  points  for  inflow.  The 
usual,  and  the  usually  adequate,  method  is  to  concentrate 
either  the  inflow  or  the  outflow  into  one,  two,  or  more  points, 
and  to  so  distribute  the  apertures  for  the  opposite  service  as 
to  effect  the  desired  distribution. 

For  certain  reasons  to  be  now  mentioned,  preference  is  to 
be  given  to  a  diffusion  of  supply  and  to  a  concentration  of 
discharge.  First,  if  wards  are  warmed  by  the  air  which  ven- 
tilates them,  heat  is  better  distributed  by  issuing  into  a  large 
room,  as  a  ward,  at  many  points,  rather  than  at  a  single  point. 
In  the  second  place,  draft  effects  are  much  less  for  equal  vol- 
ume movements  and  equal  apertures  when  they  converge  for 
discharge  than  when  the  concentrated  current  of  inflow  con- 
tinues its  shaft-like  course  athwart  the  room.  An  indraft  of  air 
will  move  in  more  or  less  compact  current  from  one  side  of 
a  room  to  another,  or  through  the  entire  length  of  a  ward; 
whereas  outflowing  air  moves  towards  its  exit  through  that 
part  of  a  sphere  which  is  made  possible  by  the  conformation 
of  walls  and  floors,  and  the  flow  becomes  perceptible  as  a  draft 
only  with  more  or  less  close  approach  to  the  aperture  of  dis- 
charge. Therefore,  concentration  in  outflow  is  less  open  to 
objection  than  aggregation  of  inflow. 

The  most  convenient,  as  well  as  the  most  effective,  place 
for  the  inflow  of  air  into  wards  is  beneath  windows.  Fresh 
air  is  then  issued  into  the  wards  between  beds  and  close  to 
patients,  and  the  current  of  cold  air  flowing  down  over  the 
windows  is  met  and  neutralized  by  a  flow  of  warm  air  rising 


Woodbridge. 

upwards  beneath  the  windows.  Ideally,  such  an  inlet  should 
be  beneath  each  window.  If,  however,  they  are  placed  at  alter- 
nate windows,  each  bed  has  then  a  supply  furnished  on  one 
side.  The  unused  wall-space  between  cots  at  the  remaining 
windows  affords  table  accommodation  to  each  bed.  The 
position  of  the  register  in  such  a  location  should  be  high 
enough  above  the  floor  to  prevent  the  register-box  from  be- 
coming a  dust-receptacle,  and  low  enough  below  the  window 
sill  to  issue  the  air  sufficiently  near  the  floor  to  prevent  cold- 
ness at  the  floor-level. 

With  such  an  arrangement  for  warm  air  inflow,  the  loca- 
tion of  discharge  may  be  through  a  single  large  fireplace  and 
flue  at  one  end  of  the  ward,  provided  the  ward  is  intended 
to  accommodate  not  more  than  ten  or  twelve  beds.  If  tin- 
number  of  beds  exceeds  twelve,  the  discharge  would  better 
be  separated;  as  in  a  ward  for  twenty-four  beds  a  vent  would 
better  be  provided  either  for  each  end  of  the  ward,  or  at  the 
central  point.  Roughly,  then,  in  accordance  with  such  a  plan, 
each  twelve  beds  should  be  furnished  with  not  less  than  six 
inlets,  and  with  not  less  than  one  ample  and  well  located  vent. 

The  practice  of  locating  a  vent  under  each  bed  is  in  the 
direction  of  unnecessary,  though  not  useless,  elaboration. 
The  breaking  -up  of  otherwise  continuous  floor-surface,  the 
harborage  afforded  for  dust,  the  in  way  cess  of  either  n 
ttr  faces  flush  with  the  floor  or  of  collars  protruding  above 
the  floor,  for  the  purpose  of  protecting  the  airway  against 
the  flowing  in  or  sweeping  in  of  floor  dirt,  ie  princi- 

pal objections  to  the  arrangement.     So  far  a-  mi.1i  locations 

of  vents  serve  to  limit  the  spread  and  to  efTed  the  quick  re 

moval  of  bed  and  lore,  and  SO  far  BS  thev  may  be 

made  useful     by  means  of  caps  and  flexible  tube 

tionS— tO  ventilate  the  bed  between  sheets  in  , 

rive  discharges  from  rectum  or  open  sores,  such  ventil 
elaboration-  arc  to  be  desired.    Only  in  exceptional  - 
however,  are  they  essentia]  or  even  important.    Th< 
necessary  toeffei  tive distribution  of  air.  Thev  ra 

able  in  exceptional  case-,  for  localizing  odon  and  impir 

Other  parts  of  hospital-  than  wards  require  adequate,  and 


24  Air  and  the  Hospital. 

in  some  cases  special,  ventilation.  The  operating-room  calls 
for  exceptional  treatment,  both  in  the  matter  of  ventilating 
and  warming.  The  depressed  condition  of  the  vitality  of  the 
patient  makes  free  ventilation  imperative.  The  necessarily 
scant  covering  for  protection  from  the  chill,  and  exposure 
to  the  cooling  effect  of  active  radiation  to  a  large  area  of  cold 
window-glass,  demands  an  elevated  temperature  of  the  room. 
The  temperature  conditions  which  are  absolutely  necessary 
for  the  protection  of  the  patient  are  often  distressing  to  the 
operator,  whose  work  is  in  itself  most  taxing,  intense,  and 
critical  for  the  patient's  life.  The  high  temperature  called 
for  by  the  impassive  and  nude  patient  is  oppressive  for 
the  operator.  For  him,  and  for  attendant  nurses,  there  are 
liable  to  be  moments  when  immediate,  though  it  may  be 
but  temporary,  relief  from  oppressive  heat,  ether  vapor,  and 
the  general  breathlessness  of  the  air  are  needed  for  freshen- 
ing the  operator,  and  even  for  insuring  the  success  of  the  op- 
eration. Quickness  of  air-change  is  then  called  for.  The 
change  desired  can  best  be  effected  by  giving  strong  exit  to 
the  air  of  the  room  from  its  ceiling,  where  air  is  hottest  and 
vapors  are  densest.  The  air  is  commonly  and  properly  dis- 
charged from  such  rooms  at  ordinary  times  near,  or  at,  the 
floor.  If  the  area  of  the  floor-discharge  airway  is  of  proper 
size,  the  flue  having  connection  at  the  ceiling  may  be  of  equal 
size.  A  large  office  fan  electrically  driven  may  be  placed 
in  this  opening,  the  press-button,  or  switch,  for  operating 
the  fan  being  within  easy  reach  of  the  surgeon  or  his  attend- 
ants. The  current  which  controls  the  fan  may  also  operate 
a  damper  for  closing  the  opening  when  the  fan  is  not  in  oper- 
ation, and  for  directing  the  outflow  to  the  vent  at  the  floor  of 
the  room.  It  has  been  found  by  experience  that  by  the  use 
of  such  a  single  device  the  quality  of  the  air  of  an  operating- 
room  may  be  given  the  quick  change  desired  for  the  reduc- 
tion either  of  temperature  or  other  oppressiveness  or  offen- 
siveness.  If  the  room  is  of  the  amphitheatre  type,  accommo- 
dating a  large  number  of  clinic  observers,  a  fan  of  suitable 
size  and  power  to  meet  the  special  conditions  is  required. 
The  air  supplied  to  operating-rooms  may  well  be  filtered 


Woodbn  15 

either  through  an  effective  wet  and  germicidal  filter, —  which 
may  be  made  of  some  thirty-six  inches  in  depth  of  finely 
broken  coke  sprayed  and  wet  with  a  suitable  germicidal 
fluid — or  else  through  a  sufficient  thickness  of  sterilized  cot- 
ton-wool. Both  processes  require  a  greater  pressure  of  air 
than  that  usually  available  for  entering  air  into  low  build 
ings  by  gravity  action;  or  else  excessively  large  surfaces  of 
filter  and  correspondingly  low  velocity  of  air-flow  through 
them,  as  where  the  air-flow  is  that  obtainable  by  gravity 
action. 

For  the  ventilation  of  sanitaries,  bathrooms,  Lockers,  and 
of  other  quarter.-,  a  slight  reduction  of  air-pressure  within 
such  rooms  should  be  maintained  in  order  to  insure  B  How 
of  air  toward  and  into  them  from  adjacent  quarter.-.  It  then 
becomes  necessary  to  produce  in  the  vent-flues  for  such 
rooms  a  stronger  aspirating  action  than  obtains  in  the  ordi 
nary  ventilating-llues  of  the  building.    Thai  >f  "pull" 

may  not  move  a  larger  air- volume  than  is  moved  by  other 
flues.  The  flue  with  a  stronger  "pull"  may  move  less  air 
than  Hues  with  a  weaker  pull.  The  essentia]  is  the  "/>/<//:" 
that  is,  the  pressure  per  square  inch  should  be  greater  than  i- 
the  pull  in  vent-flues  discharging  air  from  other  and  ordinar) 
rooms;  but  the  area  of  the  Hue-  may  be  -mall  in  proportion 
a-  the  "pull"  i-  strong.  To  effect  such  excess  of  "pulling" 
in  the  flues  in  which  it  i-  desired,  and  when  dependent 

placed  upon  gravity  action  for  the  production  of  ventilation. 

it  becomes  necessary  to  heal  such  flues  by  some  appropriate 

mean-,    such    as    Steam    COlls,    hot  water   (oil-.    <^;i-   or   lamp 

flame.   The  temperature  of  such  flues  should  be  raised  above 
the  temperature  of  the  flues  ventilating  ordinar}  room-  bj 
an  amount  equal  n>  ten  or  fifteen  or  sometimes  twenty 
degrees.    Roughly  -peaking,  when  such  flues  ate  heated  by 

steam  -111  I.m  e  tlie  minimum  amount  of  that 

be  safely  used  is  five  square  feel  I 
( rose  section  of  flue. 

An  hour--  discussion  might  well  be  given  to  the  sub 
of  the  hygiene  of  ventilating  flues  thei  iuch, 

perhaps  nol  too  nun  h,  ha-  been  written  and  spoken  in  n 


26  Air  and  the  Hospital. 

to  the  importance  of  keeping  airways,  both  supply  and  dis- 
charge, scrupulously  free  from  dust  and  dirt.  Cleanliness  is 
the  first  essential;  to  it  ventilation  is  secondary.  Cleanliness 
must  always  precede,  if  ventilation  is  to  succeed.  Dustiness 
and  dirtiness  are  less  of  a  menace,  however,  in  some  places 
than  in  others.  If  the  dust  is  in  a  flue  through  which  air  is 
continuously  passing  outward  from  a  room,  the  room  is  in 
no  way  endangered  by  the  presence  of  such  dust  and  dirt. 
If,  on  the  other  hand,  the  menace  lurks  in  the  airway  from 
which  the  room  is  supplied,  the  danger  is  the  greater.  We 
concern  ourselves  little  because  of  the  pollution  poured  into  a 
brook  or  river  rfoirw- stream.  We  are,  on  the  other  hand,  very 
—  and  rightly — particular  about  the  purity  of  the  w^-stream 
water,  if  the  stream  be  the  source  from  which  our  supply  is 
taken.  Except  for  the  protection  of  the  vicinage,  it  matters 
little  what  may  flow  out  and  away  from  the  hospital.  That 
which  goes  in  is  of  transcending  importance  to  the  hospital 
itself.  That  which  goes  out  from  the  hospital  may  be  so 
treated,  if  necessity  requires,  as  to  remove  all  offensive  and 
all  infectious  quality  from  even  the  discharged  air,  by  means 
which  cannot  be  here  described  or  discussed. 

The  principal  danger  arising  from  dusty  vent-flues  is  in 
possible  draft  reversals,  which  may  carry  with  them  the  ob- 
jectionable dust  into  rooms.  The  larger  danger  incident  to  the 
lodging  and  collecting  of  dust  in  the  supply-flues  is  in  the 
movement  of  air  over  such  dust  and  into  the  sick-rooms,  the 
air-current  supposedly  carrying  with  it  particles  of  that  dust 
loosened  from  the  deposit,  and  sometimes  dislodging  consid- 
erable quantities  of  the  dust  in  layers,  and  carrying  it  for- 
ward with  the  current  into  the  wards. 

Such  a  situation  is  assuredly  bad  enough,  yet  not  as  bad 
as  it  might  be  pictured.  The  dust  belched  forth  into  the 
wards  on  certain  occasions  would  be  that  dust  which  would 
have  entered  in  continuous  current  had  it  not  become  at- 
tached to,  and  held  by,  the  surface  of  the  piping.  To  that  ex- 
tent, therefore,  the  air-supply  to  the  wards  would  be  filtered, 
and  therefore  purer,  for  days  and  weeks,  and  it  might  be  so 
for  months  and  vears  —  until  in  a  moment's  time  the  reserved 


Woodbridge. 


accumulation  is  discharged  into  the  wards.  Meanwhile,  how- 
ever, a  change  takes  place  in  the  quality  of  that  dust,  ex- 
posed for  a  shorter  or  longer  period  to  the  blast  of  air  over 
it  and  through  it.  The  fact  has  been  proved  that  microbic 
dust  when  exposed  to  air  in  continuous  and  rapid  movement 
over  it  is  reduced  by  slow  oxidation  to  inorganic  form.  A 
series  of  tests  made  at  the  Massachusetts  Institute  of  Tech- 
nology on  dust  accumulated  in  air-flues  points  stronglv  to  the 
fact  that  such  oxidation  and  reduction  does  take  place  in  the 
dust  of  airways;  and  that.  SO  far  from  being  the  feeding  and 
breeding  grounds  of  microbic  organisms,  it  i-  almost  wholly 
free  from  germs.  In  so  far  as  that  is  true  of  dust  exposed  to 
continuously  moving  air,  such  dust  is  the  less  to  be  feared  on 
hygienic  ground.-.  Nevertheless,  if  for  no  other  reason  than 
for  the  sake  of  cleanliness,  all  lodging  and  hiding  places  for 

dust  are  to  be  avoided.     As  far  a-  is  practicable,  all  airways 

may  well  be  accessible  for  the  purpose  of  inspection  and 

cleaning.  For  this  reason,  the  mouths,  throats,  and  duct- 
way-  of  flues,  both  for  supply  and  for  discharge,  should  be 

a-  open  and  accessible  a-  are  fireplace-  and  their  line-. 

IV. 

The  means  appropriate  for  the  propulsion  of  air  through 
the  ventilating  system  of  a  hospital  art-  dependent  on  a  va« 
riety  of  <  in  umstances.    Whenever,  without  too  great  con 
on   in   the   matter  of  mechanical   accommodation,  in 

Sizes  and   places  ami   form-  of  airway-,  nature  i-  ready  and 

able,  unaided,  to  do  needed  ventilating  work,  that  work  may 

iely  and  wisely  intrusted  to  her.    II'  r  demand 
acting,  ami  her  performance  is  a-  variable  ami  fitful  a 
weather  and  wind.    She  mu-t  be  given  capacious  air* 

gauged  to  ;k  .  omplisfa  results  when  her  mood-  of  temperature 

and  wind  an-  least  favorable  to  obtaining  them.    Flue  bot 

toms  at  ground  and  flue  top-  at  roof  mu-t  be  given  mo 

vorabl(  exposure  for  her  inkle  play  upon  them.    Dam] 
and  similar  devi< es,  mu-t  be  employed  to  .  Ik  i  1.  her  frov 
in  gales  and  in  <  oldness,      '■••  hi  h  reining 


28  Air  and  the  Hospital. 

and  curbing,  the  extremes  of  excesses  in  ventilation  and  in 
coldness  of  building  would  be  reached,  and  when  the  two 
ventilation-drafts  would  become  insufferable. 

The  substitute  for  nature's  method  and  work  is  ventilating 
mechanism, — as  the  fan, — or  else  a  boosting  of  nature  by  as- 
sisting her  work  by  lending  her  heat,  which  she  seldom  if 
ever  returns.  Mechanical  ventilation  is  to  gravity  ventila- 
tion like  the  steam-driven  to  the  wind-driven  ship.  Steam 
and  enginery  are  indispensable  to  an  invariable  speed,  to  a 
steady  course,  and  to  the  schedule  sailings  of  a  ship.  Yet 
the  sail  has  not  been,  and  never  will  be,  wholly  displaced  by 
the  screw.  It  remains  a  thing  of  beauty,  and  of  world-wide 
service.  So  also  the  larger  part  of  ventilating  work  the  world 
over  is  to-day,  and  always  will  be,  done  without  mechanism. 

Where  the  airways  for  ventilating  work  can  be  large 
enough,  and  high  enough,  and  where  heat  need  not  be  used 
for  the  sole  purpose  of  producing  ventilation  flow,  there  ven- 
tilation by  gravity  action  is  always  admissible,  and  often,  if 
not  generally,  preferable.  When  the  ventilating  work  to  be 
done  is  small,  and  even  when  the  volume  of  air  used  is  large, 
but  its  use  is  intermittent  and  at  long  intervals,  then  gravity 
rather  than  mechanical  ventilation  is  found  advisable.  Small 
and  intermittent  ventilating  work  does  not  warrant  the  ex- 
pense of  an  adequate  and  largely  idle  equipment  and  the 
salary  paid  to  a  competent  engineer.  This  phase  of  the  ven- 
tilating problem  resolves  itself  into  one  of  operating  profit 
and  loss,  into  which  enter  too  large  a  number  of  factors  for 
discussion,  or  even  mention,  in  our  present  study. 

In  general,  however,  this  rule  may  be  followed :  when  ven- 
tilation is  to  be  continuous,  as  in  the  hospital;  wherever  the 
air  volumes  are,  or  should  be,  large ;  where  airways  are  long, 
or  small,  and  the  velocity  of  air- flow  must  be  high;  where 
power  is  available  in  steam  used  for  other  purposes,  or  in 
electric  service,  or  in  an  inexpensive  water  head  and  flow,  or 
even  when  gas  or  like  engines  can  be  advantageously  used; 
when  required  attendance  may  be  given  by  those  already 
employed  for  other  service;  —  then  the  conditions  are  fa- 


Woodbridge.  29 

vorable  to,  and  frequently  require,  the  use  of  mechanical 
ventilation. 

An  argument  made  in  some  quarters  against  mechanical 
ventilation  for  hospitals  is  based  on  the  necessity  of  quiet- 
ness about  the  sick,  and  on  the  assumption  that  the  use  of 
mechanism  necessarily  involves  the  noisy  whirl  of  wheels, 
or  the  rumbling  or  clattering  of  machinery,  or  the  whistling 
or  the  singing  of  the  air  as  it  frolics  into  or  frisks  out  from 
rooms  under  the  propulsion  of  the  fan.  All  such  noisy  nui- 
sances are  quite  as  avoidable  as  they  are  possible. 

A  frequently  used  substitute  for  the  fan  is  heat  in  vent- 
flues.  To  warm  air  for  admission  to  buildings  is  quite  costly 
enough.  To  again  heat  it  as  it  takes  its  flight  from  buildings 
is  to  increase  expense  ill  a  manner  to  be  justified  only  when 
other  equally  effective  methods  would  be  equally  or  increas 
ingly  costly. 

Because  the  flue  heating  method  is  simple  and  easily  ap- 
plied, and  because  it-  I  OStliness  IS  I  urrcni.  -lowly  cumulative, 
and  not  conspicuously  evident,  it  is  often  employed  to  tlie 
user's  lo>s.  To  move  a  cubic  foot  of  air  into  a  building 
through  a  heater  and  fan,  and  through  flues  to  room-,  and 
through  rooms  into  and  through  vent  Hue-,  and  to  discharge 
it  outboard,       all   that    work   should   require  a   power  rarely 

nai  hing,  and  never  exceeding,  that  required  to  raise  ten 

pounds  in  weight  through  one  fool  against  the  pull  of  gravity. 
In  a   well  designed,  accommodated,  and   installed  system  of 

ventilation  the  work  expended  on  each  cubit    foot  of  air 
moved  through  it  should  not  exceed  from  five  to  six  pounds. 

If.  on  the  other  hand,  that  (  llbic  foot  of  air  moved  through 
the  building  is  made  to  move  through  the  ventilating  system 

of  the  building  by  giving  to  it  a  rise  of  temperature  of  ten  de 
.  for  the  purpose  of  producing  an  acceleration  of  flow, 

the  power  equivalent  of  that  heat  is  ten  pounds  raised  through 
more  than   fourteen   feet   against   the  pull  of  gravity,  instead 

of  ten  pounds  raised  through  one  foot.    If  only  one  twelfth 
of  the  heal  produced  by  fuel  combustion  is  convertible  into 

•  r,  and  if  the  exhaust  steam  of  the  engine  furnishing  that 

power  is  wasted,   the  COSl   of   moving  the  air  by  raisin/ 


30  Air  and  the  Hospital. 

temperature  ten  degrees  and  the  cost  of  moving  that  air  by 
exceptionally  hard  fan-work  are  then  about  equal.  If,  how- 
ever, the  exhaust-steam  from  the  engine  driving  the  fan  is 
used  for  heating  purposes,  the  largest  cost  which  we  may 
consider  allowable  by  the  fan  method  is  about  one  third  of 
that  by  the  heated-flue  method  when  the  rise  in  flue-air 
temperature  is  but  ten  degrees.  The  higher  the  rise  of  that 
temperature  the  greater  the  loss. 

Fan-ventilation  is  therefore  to  be  generally  recommended 
for  large  hospitals  of  complicated  plan  and  construction, 
where  airways  must  be  small  and  tortuous  and  long,  and  where 
gravity  cannot  be  given  generous  provision  for  its  own  mod- 
erateness and  variableness  of  work. 

If  the  conditions  which  should  determine  the  use  and 
the  avoidance  of  fans  have  been  correctly  stated,  there  is 
manifestly  one  class  of  hospitals  to  which  the  fan  is  generally 
inappropriate. 

The  cottage  hospital  is  ideally  adapted  to  gravity  venti- 
lation. Beneath  its  wards  can  be  great  chambers,  reservoirs 
of  pure  air.  Those  chambers,  instead  of  being  cellars, —  dark, 
damp,  dismal,  dirty  places,  the  abode  of  toads,  spiders, 
and  creeping  things,  where  the  pale,  sickly  life  of  plants  runs 
out  in  slender,  eager  tendrils  toward  the  little  light  which  fil- 
ters through  some  cobwebbed  window,  or  chink  in  the  wall, — 
should  be  places  flooded  with  light;  flushed  to  the  full  with 
purest  air;  as  dry  as  sun  and  air  and  impervious  walls  and 
floor  can  make  them;  clean  as,  if  not  cleaner  than,  any  other 
part  of  the  hospital  above. 

The  ward  is  then,  as  it  were,  supported  in  mid-air.  Pure 
air  is  above  it,  beneath  it,  on  both  sides  of  it,  ready  to  flow 
into,  and  to  flush,  the  ward  whenever  and  wherever  its  serv- 
ice is  appropriately  solicited. 

Let  the  inlet  way  be  by  an  open  window  on  each  side  of 
the  basement  chamber,  one-third  square  foot  area  of  open- 
ing per  bed  in  each  opening;  let  light  and  self-operating 
checks  be  designed  and  placed  for  freely  admitting  air  on 
the  windward  side,  and  for  preventing  its  escape  on  the  lee- 
ward side;  for  each  two  beds  let  one  indirect  heater  be  hung 


Woodbridge. 


3i 


to  the  ceiling  of  the  basement,  each  heater  to  contain  not  less 
than  fifty  square  feet  of  radiation,  for  the  Philadelphia  win- 
ter climate;  let  the  heater  be  connected  with  the  ward  above 
by  sheet-metal  boxing,  an  air-pipe  of  one  square  foot  cross- 
section,  and  a  register  grating  of  one  and  one-half  square 
feet  gross  area;  let  the  ward  discharge-ventilation  be  through 
two-ninths  square  feet  of  heatable  flue  for  each  bed;  let  mix- 
ing-damper- control  the  temperature  of  air  inflow,  and 
throttling-dampers  the  volume  of  outflow;  then,  construct- 
ively, the  situation  is  complete  for  abundant  and  effective 
gravity  ventilation,  one  to  which  a  fan  would  be  as  much  out 
of  place  as  would  be  a  windmill  erected  to  help  out  a  surplus 
of  water-power. 

When,  however,  the  river  runs  dry,  then  the  windmill  finds 
its  opportunity  for  serviceable  performance.  So  also  when, 
in  ventilating  work,  the  outside  temperature  is  so  high  that 
mildly  heated  vent-flue-  become  ineffective,  then  the  fan  may 
be  most  serviceable.  The  period  of  such  needed  servi 
however,  50  short  that  its  work  had  then  generally  better  In- 
done  by  a  temporary  and  judicious  use  of  window-transoms, 
or  of  windows  themselves,  if  tr.uiM.ni>  are  wanting. 

If  the  wards  are  cooled  in  summer  by  filling  the  indii 
radiators  with  cold  water,  and  by  passing  the  ventilating-air 
through  them  to  the  wards,  then  pressure  on  the  air  in  the 
basement  chamber  is  necessary  to  lift  and  force  the  chilled 
and  heavy  air  into  the  wards. 

For  this  purpose  a  disk  fan  30*  in  diameter,  run  at 
and  quiet  speed,  will  supply  all  the  air  needed  to  twenty  t> 

A  hospital  equipped  for  such  cooling  work  mus(  have,  in  ad- 
dition to  the  inlet  windows  for  Use  when  heating  is  required, 
a  separate  window  and  >pei  ial  fan  for  dog  day  weather  work. 
When  either  is  "pen  for  action  the  other  must  be  closed. 
The    urfa<  e  foi  air  must  be  large,  and  pro] 

tioned  to  the  difference  in  temperature  between  the  • 
used  for  cooling  and  the  temperature  desired  for  the  wards. 
When  the  mean  temperature  of  water  in  the  heater  i 
and  the  temperature  of  the  air  before  passing  through  the 
i  oolers  is  o»    .  and  after  passing  through 


3  2  Air  and  the  Hospital. 

square  foot  of  the  cooler  will  cool  about  three  hundred  and 
fifty  cubic  feet  of  air  an  hour  through  150. 

The  method  is  practicable  when  an  abundance  of  cold 
spring-water  under  natural  flow  can  be  had.  Results  are, 
however,  likely  to  be  disappointing  because  of  the  increased 
relative  humidity  attending  the  chilling  of  air  when  air-dry- 
ing does  not  follow  its  cooling.  Into  the  large,  interesting, 
but  involved  question  of  artificial  cooling  by  mechanical 
refrigeration  this  paper  cannot  enter;  time  forbids  it,  and 
general  utility  does  not  invite  us  to  such  a  discussion. 

V. 

A  few  points  only  can  be  noticed  with  reference  to  the 
warming  of  hospitals.  Because  hospital  ventilation  must  be 
made  free,  the  air-quantity  necessarily  used  for  that  purpose 
is  therefore  abundant  for  conveying  heat  to  wards  and  to 
other  rooms  by  the  indirect  method  of  heating.  If  the  air 
which  ventilates  the  wards  is  also  the  vehicle  for*  the  carriage 
of  heat  for  their  warming,  then  because  the  air-supply  is 
large  the  temperature  of  the  air  entering  rooms  even  in  zero 
weather  need  be  but  little  above  the  temperature  of  the  rooms 
themselves.  Low  temperature  of  heated  air  insures  an  agree- 
able, if  not  a  hygienic,  quality  of  air,  because  not  deteriorated 
by  scorched  dust  and  the  odors  and  qualities  peculiar  to  su- 
perheated air. 

When  for  any  reason  direct  radiation  must  be  used, —  as 
is  often  the  case,  especially  in  rooms  other  than  wards, —  the 
radiators  should  be  selected  with  due  reference  to  plainness, 
smoothness,  and  accessibility  to  surface  for  cleaning.  The 
temperature  of  the  heating-surface,  especially  for  gravity 
work,  should  be  maintained  at  as  low  a  point  as  is  consistent 
with  the  proper  warming  of  the  hospital,  and  the  heating- 
surface  of  the  radiators  should  be  correspondingly  large.  In 
case  fan-power  is  used  for  moving  and  distributing  the  air, 
the  rapid  flow  of  air  over  the  indirect  heaters  makes  a  higher 
temperature  and  a  smaller  area  of  those  surfaces  admissible ; 
because  the  rapidity  of  air-movement  through  the  heater 


Woodbridge.  33 

makes  the  contact  of  air  and  its  dust  contents  too  brief  to 
admit  of  deleterious  effects,  unless  the  surface-  are  given  a 
temperature  abnormally  high. 

For  the  purpo-<-  of  giving  to  heating-surfaces  a  mild  rather 
than  a  high  temperature,  their  heating  can  be  most  suitably 
done,  and  also  their  temperature  most  perfectly  controlled, 
by  using  water  rather  than  steam  as  a  medium  of  transfer 
of  heat  from  fires  to  radiators.  The  use  of  hot  water  is  fur- 
ther to  be  recommended,  if  that  water  i>  heated  directly  by 
fires,  on  the  ground  of  economy  in  the  use  of  fuel:  first,  be- 
cause of  the  transfer  of  a  larger  proportion  of  the  heat-com- 
bustion to  radiator-  than  when  steam  is  employed;  and  sec- 
ond, because  of  the  easier  and  more  complete  regulation  of 
the  building  temperature,  which  make-  less  liable  and  un- 
necessary the  overheating  of  rooms  in  mild  weather,  and  the 
opening  of  window-  for  relief,  and  the  large  waste  of  heat 
attending  that  practice.  Economy,  therefore,  favor-  th< 
of  water  at  both  end-  of  a  system — at  the  tire>  and  at  the 

radiators.  The  first  cost  of  a  hot-water  plant,  for  equal 
heating  and  ventilating  work  with  steam,  varies  from  thirty 
per  cent  to  fifty  per  cenl  more  than  the  cost  of  a  Steam 
apparatus.  The  saving  in  fuel  by  water-boiler  heating  has 
found  by  careful  experiment  to  vary  from  fifteen  per 
•  i-nt  to  twenty  per  cent  over  the  cost  of  doing  the  same  work 

by  steam. 

A  possible  further  advantage  in  the  use  of  water,  and  for 
the  large  ini  rease  of  heating  surface  over  that  required  when 
m  is  used,  i-  in  the  availability  of  that  large  surfao 

cooling  work  in  the  summer,  already  alluded  to. 

In  the   matter  of  warming,  as  well   a-  of   ventilation,   tin 

operating  room  furnishes  opportunity,  if  not 
special  treatment.    The  eflfei  1  on  the  patient  of  tin  ' 
posure  of  thilled  window  glass  should  be  compensated  bj 

irrespondingly  heated  surface  for  radiating  to  the  ; 
a-  much  heat  as  the  bod]  1 

may  be  in  pipe  form,  carried  about  the  window  frann 
Over  (millions  and  other  part-  of  the  framework  in  a  Rlfl 
to  be  neither  <  on. pi.  UOUS  nor  light  int.  \\  h(  I 


34  Air  and  the  Hospital. 

dows  are  double  glazed,  and  with  ample  air-space  between 
the  plates,  that  space,  and  with  it  the  inner  glass,  may  be 
warmed  by  steam  or  hot  water  pipes  concealed  from  view 
within  the  space. 

VI. 

Both  time  and  subject  limitations  forbid  any  further  gen- 
eral discussion  of  the  many  detailed  applications  of  princi- 
ples to  practice,  or  of  the  adaptation  of  systems  to  special 
cases.  The  most  perfect  hospital  ward  ventilation  on  this 
continent  is  found  where  the  absence  of  a  system  is  conspic- 
uous, and  the  use  of  a  method  is  very  much  in  evidence; 
where  the  mountain  foot-hill  is  the  site,  and  where  wide 
open  windows,  night  and  day,  through  the  stillness  and  the 
storm  of  weathers,  make  the  indoors  as  much  one  with  the 
outdoors  as  is  possible;  and  where  warming  is  thought  of 
and  provided  for  only  when  clothing  for  night  or  day  is 
changed  for  its  opposite.  The  question  for  such  wards  is 
not  one  of  artificial  ventilation,  but  of  quick,  effective,  and 
least  costly  warming  for  the  half-hour  morning  and  evening 
change  of  dress.  Shall  that  be  by  closed  windows  and  great 
direct  heaters  placed  within  wards?  Or  shall  it  be  by  pow- 
erful indirect  heaters  and  fans  beneath  the  wards,  capable 
of  excessively  free  artificial  ventilation  while  warming  is  be- 
ing effected,  and  while  the  clothing  of  beds  and  of  persons  is 
being  shaken  up  or  changed,  and  are  giving  off  their  microbic 
dust  to  air? 

Probably  the  method  having  the  least  system  is  the  least 
costly  in  installation,  and  possibly  in  operation  as  well. 
Which  method  is  the  least  and  which  is  the  most  hygienic  ? 
That  is  the  paramount  question  for  us, —  the  continuance  or 
the  discontinuance  of  ventilation  for  those  one-half  hour 
periods  ? 

In  the  first  place,  the  exposure  to  whatever  menace  there 
may  be  in  closed  windows,  suspended  ventilation,  disturbed 
and  floated  germ  dust,  is  of  short  duration,  practically  one 
twenty-fourth  of  the  time  of  hospital  habitation  and  treat- 
ment.   In  the  second  place,  it  is  a  well-known  fact  that  the 


Woodbridge.  35 

quantity  of  microbic  dust  within  enclosures  is  inversely  as 
the  volume  of  air  with  which  they  are  continuously  ventilated; 
and,  what  is  more  to  our  purpose,  tl  it  a  temporary  suspen- 
sion of  ventilation,  even  in  crowded  rooms,  does  not  result 
in  markedly  increasing  the  microbic  population.  Records 
show  that  the  microbic  proportion  of  one  in  rooms  freely 
and  continuously  ventilated  frequently  becomes  nine  in  sim- 
ilar rooms  which  are  indifferently  ventilated;  and  that  the 
proportion  of  one  holds  for  some  time,  with  only  slow  cumu- 
lative change,  measured  by  days,  when  the  ventilation  of  the 
room  is  made  indifferent,  rather  than  energetic.  In  this  fact 
Is  evidence  that  the  presence  of  parasitic  dust  in  enclosures 
arises  from  its  accumulation  by  slow  aggregation  within  them, 
rather  than  from  any  temporary  suspension  or  reduction  of 
ventilation  or  the  sorties  of  microbic  battalions  from  the  gar 
risons  of  infected  furnishing,  clothing,  or  person. 

The  efficacy  of  activity  in  the  movement  of  ventilating  air 
to  carry  away,  and  to  effectively  dispose  of,  floating  dust  is 
plainly  proved,  as  is  also  the  importance  of  carrying  ventila- 
tion to  a  point  of  effecting  it  by  a  method  which  shall  insure 
the  accomplishment  of  that  important  purp 

Probably  the  records  of  the  Massachusetts  Hospital  for 
Consumptives  will  show  thai  the  daily  twenty  three  hours  of 
cyclonic  ventilation  to  which  its  wards  are  subjected  makes 
abortive  all  sallies  of  mic  robic  pests  during  the-  one  hour  per 
day  of  suspended  ventilation. 

After  .ill  is  said  and  done,  the  truth  remains  that  perfeel 
ventilation  is  fir  from  insured  by  perfection  of  system.    A 

perfeel  system  of  ventilation  is  like  a  perfect  human  body. 
That  body  without  life  is  a  corpse.  The  system  without  per 
form.ini  e    is   void. 

\  greal   hospital       what  or  where  let  US  not  name,  lest  we 

remember     boasts  of  its  fine  ventilation.   A  \  i - i t  to  the  bos 

pital,  and  a  tour  through  its  wank  gave  no  evidence  of  that 
purity  and  quality  of  air  which  good  ventilation  should  in 
sure.   Quite  to  the  contrary,  the  i  onditions  were  notably  bad. 
In  response  to  b  mild  suggestion  of  surprised  disappointment, 
the  assuranc  e  was  given,  w  ith  a  serene  i  omplai  <  m  y,  that  the 


36  Air  and  the  Hospital. 

ventilation  is  superior,  and,  indeed,  perfect;  and  an  invita- 
tion was  extended  to  inspect  it,  and  to  go  to  the  engineering 
quarters  in  the  basement  for  that  purpose.  Sure  enough, 
there  was  found  a  fine  equipment, —  boilers,  heaters,  fans, 
engines,  and  piping  to  bewilderment, —  and  in  charge  a 
smiling  engineer  ready  to  assure  all  comers  that  his  hospital 
was  the  best  ventilated  in  the  country,  because  he  had  an 
apparatus  which,  when  run  for  one- half  hour,  finely  flushed 
out  the  entire  hospital  —  so  finely,  indeed,  that  one-half  hour 
a  day  was  found  to  be  quite  enough  to  provide  good  ventila- 
tion! 

Ability  in  repose  was  reckoned  as  equal  to  ability  in  action. 
A  corpse  revivable  each  day  for  one-half  hour  would  be 
doubtfully  received  for  domicile  even  by  a  hospital. 

VII. 

Temptations  to  discuss,  or  even  to  note,  special  methods  of 
ventilation,  and  various  methods  of  heating  for  meeting  spe- 
cial requirements  of  the  several  types  of  hospitals,  are  re- 
ferred to  the  clock,  and  are  denied  by  your  patience.  There- 
fore let  the  closing  of  our  study  bring  us  back  to  its  beginning. 

The  basal  facts  of  the  universe  are  two,  energy  and  matter. 
Of  those  two,  we  are  most  sure  that  energy  exists.  Matter  is 
evident  to  our  senses  only  as  it  is  the  abode,  the  field  of  action, 
of  energy.  Energy  is  made  manifest  to  us  through  our  phys- 
ical senses  only  in  and  through  matter.  Our  bodies  are  mat- 
ter; our  lives  are  energy.  Our  bodies  are  as  infinitesimal  in 
the  great  aggregate  of  matter  as  are  our  lives  an  infinitesimal 
fragment  of  the  infinite  and  eternal  energy.  The  energy  that 
is  in  our  body,  and  that  without  our  body,  and  at  our  con- 
venience and  command,  is  under  the  direction  of  the  intelli- 
gence and  the  will  with  which  we  are  endowed  as  the  off- 
spring of  God,  and  through  which  we  lay  hold  of  that  of 
Him  and  His  within  the  reach  of  our  taking,  appropriating, 
and  using. 

In  the  carbon  of  food  which  grows  out  of  the  earth,  and  in 
the  oxygen  of  the  air  which  inswathes  the  earth,  are  the  tan- 


Woodbridge. 


37 


gible  souk  es  of  our  vital  energy.  One  is  forthcoming  through 
man's  co-operative  effort;  the  other,  in  immense  store,  is  pro- 
vided and  replenished  without  man's  agency.  Crudeness, 
coarseness,  variableness,  and  taintedness,  in  quality  or  in 
serving,  characterize  man's  productive  work.  Perfect] 
and  completeness,  invariableness  and  taintlessness,  charac- 
terize that  which  is  from  the  Giver  of  every  good  and 
perfect  gift.  So  also,  imperfection  and  impurity  on  the  side 
of  that  which  is  produced  through  man's  agency  is  not  to 
his  hurt,  as  is  defect  in  that  which  God  supplier  Air  must  be 
pure.  Food  may  be,  had  better  be,  but  need  not  be,  pure. 
Therefore,  the  question  with  man  should  be,  What  limita- 
tion must  of  necessity,  for  the  protection  and  perfection  of 
his  life,  be  put  on  air-supply?  and  not.  What  i^  the  least  air- 
supply  that  is  tolerable  or  requisite  to  the  continuance  of  life? 
The  question  of  vital  economy  is  not,  What  least  will  keep 
the  vital  Same  of  life  from  extinction?  but,  What  will  hold 
it  to  it>  fullest  glow  without  flickering  it,  or  extinguishing  it, 
in  drafts? 

Enfeebled   vitality,  the  habitat  of  hospitals,  is  in  a   por- 
tion of  corresponding  sensitiveness  and  susceptibility  to  en 
ergy  contributing  or  energy  detracting  environment.  Whether, 

therefore,   it    be   in  the  matter  of  food  or  of  air,  to  the  sick, 

above  all  others,  energy  restoratives  should  be  furnished  in 

the  purest  and  the  most  life  giving  form. 

Pure  air  i>  tantamount  to  abundance  of  air.  It  i^  the 
function  of  the  trained  engineer  to  furnish  air  volume  to 
the  maximum,  and  to  reduce  both  of  the  restricting  drafts  to 
a  minimum.    It  is  the  function  of  the  hospital  management 

to  deal  with  the  matter  of  proper  balance  between  vital  profits 
and  bank  drafts. 

'I'Ik   weights  are,  on  the  one  side,  the  value  of  vital 
of  life, either  in  mere  existence  or  in  varied  di 
and  intensity;  and,  on  the  other  side,  the  value  of  the  dollar. 
The  divine  revelation,  the  pulpit,  the  book  and  the  platform 

of  moral  ethii  S,  the  in-tim  live  value  ea.  h  living 

on  his  lite,     these  are  th<  from  width  we  learn  the 

hi  of  the  vital  ein  simple  probl 


$8  Air  and  the  Hospital. 

As  to  the  other  factor,  the  dollar  cost  of  air,  if  one  shaft  of 
revealing  light  shall  do  anything  to  disclose  and  dislodge 
that  sordid  obstacle  to  the  completeness  of  hospital  service, 
the  purpose  and  hope  of  this  paper  will  be  abundantly  and 
thankfully  realized. 


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